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The next step in learning from sentinel events in healthcare. | PSNet

psnet.ahrq.gov/issue/next-step-learning-sentinel-events-healthcare

June 12, 2024 - Commentary The next step in learning from sentinel events in healthcare. Citation Text: Bos K, Dongelmans DA, Greuters S, et al. The next step in learning from sentinel events in healthcare. BMJ Open Qual. 2020;9(1):e000739. doi:10.1136/bmjoq-2019-000739. Copy Citation Format: …

The urgent need to improve health care quality. Institute of Medicine National Roundtable on Health Care Quality. | PSNet

psnet.ahrq.gov/issue/urgent-need-improve-health-care-quality-institute-medicine-national-roundtable-health-care

May 27, 2015 - Commentary Classic The urgent need to improve health care quality. Institute of Medicine National Roundtable on Health Care Quality. Citation Text: Chassin MR, Galvin RW. The urgent need to improve health care quality. Institute of Medicine National Roundtable o…

A quality improvement initiative using peer audit and feedback to improve compliance with the surgical safety checklist. | PSNet

psnet.ahrq.gov/issue/quality-improvement-initiative-using-peer-audit-and-feedback-improve-compliance-surgical

March 24, 2021 - Study A quality improvement initiative using peer audit and feedback to improve compliance with the surgical safety checklist. Citation Text: Fridrich A, Imhof A, Staender S, et al. A quality improvement initiative using peer audit and feedback to improve compliance. Int J Qual Health C…

Two-year longitudinal assessment of physicians' perceptions after replacement of a longstanding homegrown electronic health record: does a J-curve of satisfaction really exist? | PSNet

psnet.ahrq.gov/issue/two-year-longitudinal-assessment-physicians-perceptions-after-replacement-longstanding

December 31, 2014 - Study Two-year longitudinal assessment of physicians' perceptions after replacement of a longstanding homegrown electronic health record: does a J-curve of satisfaction really exist? Citation Text: Hanauer DA, Branford GL, Greenberg G, et al. Two-year longitudinal assessment of physician…

Implementing patient and family involvement interventions for promoting patient safety: a systematic review and meta-analysis. | PSNet

psnet.ahrq.gov/issue/implementing-patient-and-family-involvement-interventions-promoting-patient-safety-systematic

February 02, 2022 - Review Implementing patient and family involvement interventions for promoting patient safety: a systematic review and meta-analysis. Citation Text: Giap T-T-T, Park M. Implementing patient and family involvement interventions for promoting patient safety. J Patient Saf. 2021;17(2):131-1…

Hospital infection prevention: how much can we prevent and how hard should we try? | PSNet

psnet.ahrq.gov/issue/hospital-infection-prevention-how-much-can-we-prevent-and-how-hard-should-we-try

November 16, 2022 - Review Hospital infection prevention: how much can we prevent and how hard should we try? Citation Text: Bearman G, Doll M, Cooper K, et al. Hospital Infection Prevention: How Much Can We Prevent and How Hard Should We Try? Curr Infect Dis Rep. 2019;21(1):2. doi:10.1007/s11908-019-0660-2…

Systematic review of interventions to improve safety and quality of anticoagulant prescribing for therapeutic indications for hospital inpatients | PSNet

psnet.ahrq.gov/issue/systematic-review-interventions-improve-safety-and-quality-anticoagulant-prescribing

January 12, 2022 - Review Systematic review of interventions to improve safety and quality of anticoagulant prescribing for therapeutic indications for hospital inpatients Citation Text: Systematic review of interventions to improve safety and quality of anticoagulant prescribing for therapeutic indication…

Psychological intervention to improve communication and patient safety in obstetrics: examination of the health action process approach. | PSNet

psnet.ahrq.gov/issue/psychological-intervention-improve-communication-and-patient-safety-obstetrics-examination

April 21, 2021 - Study Psychological intervention to improve communication and patient safety in obstetrics: examination of the health action process approach. Citation Text: Derksen C, Kötting L, Keller FM, et al. Psychological intervention to improve communication and patient safety in obstetrics: exam…

Analysis of an academic medical center’s corrective action plan in response to fatal medication error using the Institute for Safe Medication Practices’ Hierarchy of Effectiveness. | PSNet

psnet.ahrq.gov/issue/analysis-academic-medical-centers-corrective-action-plan-response-fatal-medication-error

February 21, 2018 - Commentary Analysis of an academic medical center’s corrective action plan in response to fatal medication error using the Institute for Safe Medication Practices’ Hierarchy of Effectiveness. Citation Text: Stolte AR, Siwy YM, Tanios SB, et al. Analysis of an academic medical center’s co…

Errors detected in pediatric oral liquid medication doses prepared in an automated workflow management system. | PSNet

psnet.ahrq.gov/issue/errors-detected-pediatric-oral-liquid-medication-doses-prepared-automated-workflow-management

June 22, 2009 - Study Errors detected in pediatric oral liquid medication doses prepared in an automated workflow management system. Citation Text: Bledsoe S, Van Buskirk A, Falconer J, et al. Errors detected in pediatric oral liquid medication doses prepared in an automated workflow management system. …

Relationship between job burnout, psychosocial factors and health care–associated infections in critical care units. | PSNet

psnet.ahrq.gov/issue/relationship-between-job-burnout-psychosocial-factors-and-health-care-associated-infections

January 12, 2022 - Study Relationship between job burnout, psychosocial factors and health care–associated infections in critical care units. Citation Text: Galletta M, Portoghese I, D'Aloja E, et al. Relationship between job burnout, psychosocial factors and health care-associated infections in critical c…

The problem with root cause analysis. | PSNet

psnet.ahrq.gov/issue/problem-root-cause-analysis

August 28, 2024 - Commentary The problem with root cause analysis. Citation Text: Peerally MF, Carr S, Waring J, et al. The problem with root cause analysis. BMJ Qual Saf. 2017;26(5):417-422. doi:10.1136/bmjqs-2016-005511. Copy Citation Format: DOI Google Scholar PubMed BibTeX EndNote X3 XML…

Patterns of communication breakdowns resulting in injury to surgical patients. | PSNet

psnet.ahrq.gov/issue/patterns-communication-breakdowns-resulting-injury-surgical-patients

March 03, 2011 - Study Classic Patterns of communication breakdowns resulting in injury to surgical patients. Citation Text: Greenberg CC, Regenbogen SE, Studdert DM, et al. Patterns of communication breakdowns resulting in injury to surgical patients. J Am Coll Surg. 2007;204…

Effect of noise on auditory processing in the operating room. | PSNet

psnet.ahrq.gov/issue/effect-noise-auditory-processing-operating-room

November 16, 2022 - Study Effect of noise on auditory processing in the operating room. Citation Text: Way J, Long A, Weihing J, et al. Effect of noise on auditory processing in the operating room. J Am Coll Surg. 2013;216(5):933-8. doi:10.1016/j.jamcollsurg.2012.12.048. Copy Citation Format: …

Seniors managing multiple medications: using mixed methods to view the home care safety lens. | PSNet

psnet.ahrq.gov/issue/seniors-managing-multiple-medications-using-mixed-methods-view-home-care-safety-lens

June 23, 2021 - Study Seniors managing multiple medications: using mixed methods to view the home care safety lens. Citation Text: Lang A, Macdonald M, Marck P, et al. Seniors managing multiple medications: using mixed methods to view the home care safety lens. BMC Health Serv Res. 2015;15:548. doi:10.1…

Characterising ICU–ward handoffs at three academic medical centres: process and perceptions. | PSNet

psnet.ahrq.gov/issue/characterising-icu-ward-handoffs-three-academic-medical-centres-process-and-perceptions

September 27, 2023 - Study Characterising ICU–ward handoffs at three academic medical centres: process and perceptions. Citation Text: Santhosh L, Lyons PG, Rojas JC, et al. Characterising ICU-ward handoffs at three academic medical centres: process and perceptions. BMJ Qual Saf. 2019;28(8):627-634. doi:10.1…

Clinical communities at Johns Hopkins Medicine: an emerging approach to quality improvement. | PSNet

psnet.ahrq.gov/issue/clinical-communities-johns-hopkins-medicine-emerging-approach-quality-improvement

November 16, 2022 - Commentary Clinical communities at Johns Hopkins Medicine: an emerging approach to quality improvement. Citation Text: Gould LJ, Wachter PA, Aboumatar HJ, et al. Clinical Communities at Johns Hopkins Medicine: An Emerging Approach to Quality Improvement. Jt Comm J Qual Patient Saf. 2015;…

What we can do about maternal mortality—and how to do it quickly. | PSNet

psnet.ahrq.gov/issue/what-we-can-do-about-maternal-mortality-and-how-do-it-quickly

September 01, 2016 - Commentary Emerging Classic What we can do about maternal mortality—and how to do it quickly. Citation Text: Mann S, Hollier LM, McKay K, et al. What We Can Do about Maternal Mortality - And How to Do It Quickly. New Engl J Med. 2018;379(18):1689-1691. doi:10.10…

Designing for distractions: a human factors approach to decreasing interruptions at a centralised medication station. | PSNet

psnet.ahrq.gov/issue/designing-distractions-human-factors-approach-decreasing-interruptions-centralised-medication

July 27, 2018 - Study Designing for distractions: a human factors approach to decreasing interruptions at a centralised medication station. Citation Text: Colligan L, Guerlain S, Steck SE, et al. Designing for distractions: a human factors approach to decreasing interruptions at a centralised medication…

What became of the 'eyes and the ears'?: exploring the challenges to reporting poor quality of care among trainee medical staff. | PSNet

psnet.ahrq.gov/issue/what-became-eyes-and-ears-exploring-challenges-reporting-poor-quality-care-among-trainee

June 24, 2020 - Commentary What became of the 'eyes and the ears'?: exploring the challenges to reporting poor quality of care among trainee medical staff. Citation Text: Berry P. What became of the ‘eyes and the ears’?: exploring the challenges to reporting poor quality of care among trainee medical st…

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